1. UCI MICU Case Presentation

2. HPI CC: HA, fever, weakness, and nausea x 2 days
HPI: 58 y/o M who presented to UCI ED
8/3: pt. developed headache w/ photophobia and phonophobia that resolved with Tylenol
8/4: Patient received HD which was followed by nausea, restlessness and fatigue and he then became agitated & restless
8/5: Presented to UCI’s ED

3. PMHx ESRD 2/2 diabetic nephropathy with LUE AVF, HD MWF
Anemia 2/2 ESRD
IDDM
Uncontrolled HTN
Diastolic HF with EF 63% (3/5/14)
Pancytopenia
Surgeries
LUE AVF 2010
Amputations= R 2nd toe (2011), L 1st toe (1995)

4. Meds/Allergies/FHx/SHx
Renelva 1600 mg TID
Phoslo 667 mg 2 tablets TID
Metoprolol 100 mg BID
Clonidine 0.1 mg TID
Amlodipine 5 mg 4 times per wk on non-HD days
Ranitidine 150 mg qday
Tradjenta 5 mg qday
Lantus 14 u qday
Allergies: NKDA
FHx: h/o DM2 in both sides of family. No renal issues or cancers.
SHx
No EtOH, smoking, IV drugs
lives at home in Santa Ana with family and is retired

5. ED Course VS: T 102.5, P 85, BP 183/90 R 16 O2 98on RA
Gen: sick, vomiting x1 during interview, altered, AOx2, states year is 1940
HEENT: nc/at, anicteric sclera, MMM, EOMI, PERRL
Cardio: RRR, +S1, S2, no m/r/g, no JVD, no carotid bruits. Palpable thrill in R radial artery from AVF.
Pulm: CTAB, no w/r/r, normal work of breathing
GI: +BS, soft, nt/nd, no hepatosplenomegaly
Skin: no c/c/e
Neuro: face symmetric, equivocal sensation in cranial V1,2,3 distribution, 5/5 facial strength, tongue midline, puffs cheeks, smiles. Intention tremor present on finger to nose test. No pronator drift.
Musc: 5/5 muscle strength in all major muscle groups of BUE and BLE.

6. Labs

7. Labs cont’d

8. CXR

9. ED Course CT Head: LP was attempted and aborted 2/2 agitation
No evidence of acute intracranial hemorrhage, mass effect or hydrocephalus
LP was attempted and aborted 2/2 agitation
Patient admitted to family medicine

10. Hosp Course 8/5: 8/6: Started on Vanc/Zosyn for possible pneumonia
LP planned for next day
Plans for MRI
8/6:
Patient with worsening rigors, fevers and AMS
Primary team concerned for meningitis vs endocarditis vs pulm embolism
Patient transferred to MICU and abx coverage changed to
Vanc, Cefepime, Ampicillin, Acyclovir
LP performed

11. CSF Results WBC added = WBC blood x RBC CSF/RBC blood
1 WBC for every 750

12. Labs/Cultures: HIV: negative Coccidioides IgG/IgM: negative
Crypo antigen: negative
Mycoplasma IgG/IgM: negative
Histoplasma: negative
Pregnancy test: Negtaive
Cultures
Sputum (8/7):  NGTD
Bld cx (8/4): NGTD
Repeat bld cx (8/6)-AVF: NGTD

13. CSF Cultures Enterovirus: negative Viral culture: no virus isolated
VZV: negative
Bacterial culture: NGTD
Fungal culture: negative
Acid fast bacillus (TB): negative
Cryptococcus: negative
HSV1/2: negative

14. Hosp Course 8/6: Tonic clonic seizure like activity observed
Loaded with Keppra
EEG: Moderate degree of generalized cerebral dysfunction with no epileptiform abnormalities

15. 4 days later

16. West Nile Meningoencephalitis
Diagnosis…
West Nile Meningoencephalitis

17. West Nile Virus Symptoms develop in 30-40% of those infected
Life long immunity
Incubation period: 2-14 days
Longer among immunosuppressed patients
Common presentation: low grade fever, headache, malaise, back pain for 3-6 days before presentation
Can present as meningitis vs encephalitis vs acute flaccid paralysis
25-50% of patients develop a rash
Can lead to acute flaccid paralysis
Maculopapular involving the chest, back and arms and lasts for less than a week; associated with less invasive disease

19. West Nile Virus Diagnosis: IgG + IgM CSF and serum
Plasma West Nile virus RNA
CSF:
Pleocytosis with lymphocytic predominance
Increased protein
Normal glucose
CT head usually reveals no acute findings
MRI shows increased sign intensity in brain stem
EEG shows generalized, continuous slowing
IgM seroconversion occurs in 4 days and IgG in 8 days
Plasma RNA 9 days

20. West Nile Virus Treatment: Prognosis: Supportive measures
IVIG: Been suggested as possible therapy; however, no evidence to support its use
Prognosis:
30-40% of patients achieve full recovery at 12 months
30-40% fatality rate
30-40% will have long term neurological deficits
Long term neurological sequela: fatigue, word finding difficulty